Provider Demographics
NPI:1568546521
Name:GONZALES, EDMOND T (MD)
Entity Type:Individual
Prefix:
First Name:EDMOND
Middle Name:T
Last Name:GONZALES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 GREENWAY PLZ
Mailing Address - Street 2:SUITE 900
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77046-0297
Mailing Address - Country:US
Mailing Address - Phone:713-798-1750
Mailing Address - Fax:713-798-1144
Practice Address - Street 1:6701 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2316
Practice Address - Country:US
Practice Address - Phone:832-822-3160
Practice Address - Fax:832-825-3159
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE31812088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136179204Medicaid
TXP0K069522OtherCSHCN
TX136179206OtherCSHCN
TX136179205Medicaid
E80312Medicare UPIN
TX136179204Medicaid
TXP0K069522OtherCSHCN
80W615Medicare PIN